Telebriefing TranscriptCDC Announces Rubella, Once a Major Cause of Birth Defects, Is No
Longer a Health Threat in the U.S.

March 21, 2005

DR. STEVEN COCHI, ACTING DIRECTOR, CDCS NATIONAL IMMUNIZATION PROGRAM:
Good morning. We have two very distinguished guests with us this morning, Dr.
Julie Gerberding, the Director of the Centers for Disease Control and
Prevention, and Dr. Mirta Roses, who is the Regional Director of the Pan
American Health Organization.

We would like to start the program this morning by having Dr. Gerberding
tell us about a very special announcement that she would like to make. Dr.
Gerberding?

DR. GERBERDING: We are delighted to be here today to formally and
officially declare that rubella has been eliminated from the United States.
This is a major milestone in the path toward eliminating rubella in other
parts of the world, including the Western Hemisphere and other regions that
have committed to this very, very important health goal.

But what does it really mean to say we've eliminated rubella? What it
means I think is very nicely illustrated on this graphic here. In the 1960s,
many, many thousands of children in this country developed rubella. Rubella
is the disease that many of us remember as children--the three-day measles or
the soft measles, usually not a particularly severe disease for young
children, but a devastating disease if women acquire it during pregnancy
because it is the cause of the Congenital Rubella Syndrome. That is a very,
very serious condition that does result in birth defects, and death, and
other complications for unborn children.

So, in the 1960s in this country, we had very large outbreaks of rubella.
I was one of those statistics, and I'm sure many people my age or older also
remember outbreaks of rubella in their schools. The vaccine was introduced in
the late part of the '60s and, for a while, the vaccine was beginning to be
used. We were seeing better and better control of rubella. But over time, as
you can see in that red line on this graphic, we began to see fewer and fewer
cases as immunization rates got higher and higher and higher.

And for the last several years in the United States, we have just had very
few cases of rubella, and, recently, the cases that we do have are not cases
that are being transmitted in the United States; they are cases that have
been imported from other areas of the world where immunization rates are not
as high as they are here in the U.S.

So we feel it's very important, after the input of scientists and experts
from a variety of reputable and scientific organizations, to make a clear
statement that this is an achievement. We owe our success to the wonderful
people in the immunization communities across the United States whove been
working hard to vaccinate children.

But the story is not done yet. There are amazing progress underway in
other parts of the Western Hemisphere, which you'll hear about in a minute,
but there are still parts of the world where immunization is not common or
not common enough to prevent children from developing Congenital Rubella
Syndrome. So, in this country, while we can celebrate this milestone, we also
have to remain vigilant because, as we say in public health, our network is
only as strong as the weakest link. And as long as there is rubella anywhere
in the world, there could be rubella in our children, too. So we have to
sustain our commitment to immunization. We have to strengthen all of the
links in the network, and we have to do everything possible to protect the
health of children here within our country, as well as beyond.

Thank you for your interest today in celebrating this occasion. We look
forward to further celebrations as more rubella milestones are reached in the
future. Thank you.

DR. COCHI: Thank you, Dr. Gerberding.

Now, building on the success in the United States, the Pan American Health
Organization has launched a regional initiative, and I would like to call on
Dr. Mirta Roses, the Regional Director of the Pan American Health
Organization, to say a few words about that initiative.

DR. ROSES PERIAGO: Thank you. Good morning. We are really extremely happy
to be here with Julie, as they announce this tremendous success with the
rubella elimination and the Congenital Rubella Syndrome elimination. It is
always good to have a party and such a kind of party because, in this
hemisphere, we have become very used to celebrations like this. Sometimes it
starts in one country, sometimes in another, but I think that each country
deserves, and the children of each country deserve, to have a huge party when
we achieve this kind of success.

As they were mentioning before me, Julie and Steven, I think that we have
been partnering with CDC for so many years in order to really ensure that the
successes, and the experiences, and the lessons learned and the creativity
and innovation in one country serves the rest of the Western Hemisphere at
least. And I think that the Region of the Americas is leading in the field of
immunization.

In 2003, the Ministers of Health of all the Region of the Americas decided
to declare their commitment toward elimination of rubella and Rubella
Congenital Syndrome, based on the successes already achieved for measles
elimination and, also, as they were saying, some of the countries, together
with the U.S., Canada, Panama, Cuba, have already started 30 years ago to
immunize their newborns with rubella as the vaccine became available. And so
we have cohorts of people that have been protected in these countries, and
the possibility of elimination became clearer.

But then more recently, after this decision by all the ministers, and the
goal is 2010--so we are going in a good track now with this first country to
be declared, right on the goal--I think that we have made a lot of progress,
and particularly because most of the countries now in the region have
incorporated the vaccine, but many others are, also, catching up in terms of
deciding to immunize the adult population so that they will shorten the time
that is required to really immunize the people.

And we have had tremendous success for the first time in the challenging
activity of reaching to nontraditional groups of people like adults,
particularly men and women. Many countries in the region have decided to do
immunization weeks, especially to reach adult populations, and many countries
have been very innovative in how to solve, how to monitor, how to convince
the public about immunization.

And this success that we are having with the rubella is, also, opening a
new road and the possibility for improving the access to other adult
populations for influenza, eventually for the Papilloma virus vaccine,
eventually for the HIV/AIDS vaccine, when they become available.

So we are learning and, at the same time, we are celebrating. The
region--Julie mentioned the situation in the U.S.--but the region was having
around between 25- and 30,000 cases, and this has dropped dramatically. I'm
talking about Congenital Syndrome. And the impact, the economic impact of
this, particularly in poor settings, you can imagine what it means to a poor
family to have a newborn with disabilities, with very serious defects and how
this impairs their progress and the possibility even for the whole family to
improve their situations.

So this is, also, a very important, in this case, a very important
instrument, also, for poverty reduction in our region--to keep the equity
immunization and to prevent families for having more pain and deaths and
disabilities that will impair their possibility of success, of development,
of improvement of their condition.

We are always, also, having around 100,000 cases of rubella or more,
several outbreaks. We are now with almost 99-percent reduction of the cases
reported in the region. We have less than 2,000 cases last year, and now we
are moving all of us together for another, the third Immunization Week of the
Americas that is going to be celebrated in April, end of April this year. The
target last year for all the package of immunization was around 45, 46
million people. We are more ambitious this year because all the countries of
the Americas are participating, and we hope that the people that are in
distant places or that are difficult to reach like people living in border
areas or from very vulnerable or poor groups are going to be, also, part of
this important immunization week.

And we really thank CDC for having been our partner for more than two
decades, in celebrating the achievements of immunization for the region.
Thank you.

DR. COCHI: Thank you very much, Dr. Roses.

And now I'd like to open the floor to questions and answers for Dr.
Gerberding and Dr. Roses.

Ms. Anita Manning.

QUESTIONER: Is the USA the first country to eliminate rubella anywhere in
the world? And then the second--well, actually, can I ask all three of them
at once? I wanted to ask about the nine cases in 2004. Can you tell us about
those? Were they all in people who had immigrated to this country? And then
what year was the vaccine licensed?

DR. GERBERDING: Thank you. The vaccine was licensed in 1969. I just
checked that Dr. Cochi to be sure I had that right.

And the cases of rubella that occurred in the past recent timeframes are
cases that were acquired in mothers who were infected in their country of
origin and brought the virus to the United States or in children born to
families from other parts of the world. So, basically, when we say
"eliminated," what we really mean is that we are not transmitting the virus
from endogenous U.S. cases, but the virus itself has been imported and then
caused disease in a vulnerable person--either someone who wasn't vaccinated
in their country of origin or, potentially, someone here who missed
immunization.

And the first question about the countries. Cuba, actually, eliminated
rubella in the 1990s and declared. It probably represents the first country
to make that declaration. So the U.S. is not first, but we are still very
happy to be where we are today.

QUESTIONER: Thank you. Two questions.

First of all, you touched on this, and I wonder if you might address in
more detail the continued need for immunizations. I think many parents may
see the headline of this and go, "Oh, great. We no longer need immunizations
for this." You addressed that. I wonder if you might touch on that in more
detail.

And, secondly, given the fact that we still do have rubella in other
countries, what is the possibility that it may, again, reinfect this country
in a large manner?

DR. GERBERDING: The goal in the United States, ultimately, is to have all
children vaccinated effectively against Rubella and the other
vaccine-preventable childhood illnesses because we are at constant risk for
reintroduction of the virus from other parts of the world. We cannot afford
to relax our emphasis on immunization now. This is exactly the time when we
need to strengthen our emphasis on immunization even further.

The MMR vaccine is a wonderful vaccine. It saves lives, but also protects
children now and will protect them as they become adults and could be at risk
for acquiring rubella in adulthood and then being at especially high risk for
causing infection in expectant numbers. So this is a time where we need to do
even more to strengthen our immunization, not less.

Are there questions from the phone?

OPERATOR: Thank you. We do have a question from Helen Branswell with the
Canadian Press.

QUESTIONER: Hi. Thank you for taking my question. I'm wondering--I'm sorry
to ask a basic question--is there any animal reservoir of rubella? The reason
I ask is because I am wondering if at some point you could--similar campaigns
were successful in other parts of the world in eradicating rubella in humans,
would we at some point be able to essentially wipe it off the face of the
Earth or would there always be some risk of reintroduction from another
source?

DR. GERBERDING: Rubella is a disease of humans, so it is, theoretically,
possible that rubella could be eradicated. But right now PAHO, and so for the
Western Hemisphere, we have declared the goal of elimination. There are other
regions of the world that have declared an elimination goal, but the entire
world right now has not yet been able to make that commitment because of
competing priorities and resource and distribution problems.

So, in theory, eradication is a possible goal down the road, but right now
we're concentrating on elimination because that is feasible, and that's, of
course, the first step.

DR. GERBERDING: Next?

OPERATOR: Thank you. Tom Maugh, with the Los Angeles Times, your line is
now open.

QUESTIONER: There are pockets of resistance to MMR because of the
controversy about the potential link to autism. Has that been impeding your
progress in achieving the elimination?

DR. GERBERDING: I think the concerns about vaccine safety are something
that all parents have a vested interest in, clinicians are concerned about
that, and, of course, so is CDC and PAHO.

Fortunately, we have been able to increase our vaccine coverage over the
last several years, despite some of the concerns that have been expressed,
and we just need to emphasize that right now there is no evidence of autism
or other harm associated with the MMR vaccine in the area of developmental
delays or disabilities. So the evidence indicates that this is a safe and
effective vaccine, and we need to emphasize its [audio break].

QUESTIONER: I have got two questions. One is on adult vaccination. Can you
go over the issues there, both for the U.S. and for the Americas? And, also,
now that rubella, there's been a success with rubella, can you predict what
disease would be next?

DR. GERBERDING: With respect to immunization of adults for rubella, women
of child-bearing age who do not have a history of immunization or immunity,
of course, should be vaccinated against rubella to protect them from even the
remote possibility that they would come in contact with someone who was
carrying rubella. So, even in the context of a country that has eliminated
the endogenous or the transmission within the country, it is still very
important that all people, and especially expectant mothers have rubella
vaccination.

In terms of what comes next, I think we are still working on what comes
next, right now, focusing on achievement of the goals at hand, working toward
the global reduction in measles, with the goal of achieving a 50-percent
reduction by 2005, which it looks like we're likely to achieve globally, but
a long way to go with measles internationally. So there is a lot more work to
go, and I'll let Dr. Roses comment on measles and the hemisphere.

DR. ROSES PERIAGO: Well, in the hemisphere, I think that, since 1998,
several countries--and 1999, also--several countries introduced adult
vaccination because, as I mentioned, this is a strategy that will shorten the
time and accelerate the progress.

In the past, when the vaccines were introduced in several countries, like
30 years ago, of course, now we have a cohort of people that have been very
well immunized, but that is not the situation in all of the countries of the
region. That is why, since 1998, and particularly after the ministers
declared the goal for 2010, many countries have started vaccinating adult
populations, so that we will go, both ends let's say, and reduce the gap and
the possibility of transmission, and also because we don't want to get some
of the people in reproductive age, particularly, women in reproductive age,
as Julie was mentioning, be the ones that are susceptible for an imported
case because then you will increase the risk for those people.

So I think that this has been a very important and innovative measure. And
as I was mentioning, we will also have repercussions for the introduction and
coverage of other antigens that not all of the countries have the full
package as the U.S. has because of competing priorities or resource
allocation. And this has built trust in the health sector for reaching adult
population with the appropriate vaccine. So I think that that has been a
tremendous success, also.

DR. GERBERDING: Let's take another phone question, please.

OPERATOR: Thank you. We have no questions at this time. Again, to ask a
question, please press star one.

We do have a question from Angela Stewart from the Star Ledger Newspaper.

QUESTIONER: Dr. Periago, can you be more specific when you're talking
about the countries where rubella may still be a problem. Can you give us
some idea?

QUESTIONER: Yeah, I wanted Dr. Periago to maybe be more specific with
regard to the countries where rubella may still be a problem, where there are
still significant outbreaks.

DR. ROSES PERIAGO: Well, we only had like 1,600 cases last year for all
the hemisphere, so we have not had any particularly important outbreak, I
would say, but rather small clusters of cases in countries where we still
have not completely reached the immunization coverage.

The countries in the English-speaking Caribbean are fully involved in the
campaign, and three of the Andean countries are now, in 2005 and 2006, going
to a joint campaign in order to cover the people. I would say that we have
pockets in different countries, but no country, particularly, at this point
in time, is outside.

I think that the three countries that are going to be totally on board in
2006, not yet in 2005, is the Hispaniola Island, you know, both Dominican
Republic and Haiti, and I think that we are, also, with Guatemala, going to
make especially, for these are the three countries that are still--we are all
working together in order for them to--to guarantee the resources that they
need and the operational strengthening of their health sector to reach all of
the people. These are the only three countries still that we are planning to
have fully on board by 2006.

DR. GERBERDING: Next question.

QUESTIONER: I have a question. First, being when was the last time the
United States saw [audio break] and, also, what year would you suspect that
there might be global eradication of rubella?

DR. GERBERDING: Ill let Dr. Cochi answer the question.

DR. COCHI: As far as the first question is concerned, it really was the
year 2000 when we had the last circulation or spread of rubella virus
indigenously in the United States. So we have been subject only to
importations and very limited spread from the imported cases since the year
2000. Could you repeat the second question? I am sorry.

QUESTIONER: When might we see the global eradication of rubella?

DR. COCHI: I think this may be a long-term goal, but right now the world
needs to focus its resources on completing polio eradication and the already
existing initiative to reduce measles deaths worldwide by the end of this
year, as well as the many other global immunization goals that we have. That
can be taken up I think in due time, but we are still a ways away from that.

DR. GERBERDING: Other questions?

QUESTIONER: I just had a question to sort of define what you mean by
sustained outbreaks. There are still people in this country who lack immunity
sufficient to prevent themselves from being infected with rubella, if a case
is introduced. So how do you define a sustained outbreak and when was the
last sustained outbreak?

DR. GERBERDING: When we have a case of rubella in this country, the case
is investigated, and so an evaluation is done to try to understand what might
have been the source of the rubella, is there evidence of transmission to
others who are not adequately protected, and is there any evidence that that
individual has served as a source of transmission to other people.

So, when we say "sustained transmission," we mean that those
investigations have revealed linkages where one person got it, and they were
connected with somebody else, who was connected with somebody else, and we
can cluster the cases in place and time or by other factors that would be
strong evidence that they were linked as a set of transmissions--one person
gave it to somebody else who gave it to a third person.

That's what we have not been able to identify since 2000. We have an
individual case, but even after intensive assessment, no evidence that that
individual has infected anybody else. But you are very right. The fact that
we don't have 100-percent protection of our population means that if we had
enough introductions or there was clustering of very susceptible people, then
we could see sustained transmission again. And one more time, that is why we
are putting so much emphasis on trying to sustain the highest possible
vaccine coverages. Any other questions from the telephone?

OPERATOR: We have no questions from the phone lines, Doctor.

DR. GERBERDING: Going once, going twice for questions from the room.

[No response.]

DR. GERBERDING: Thank you very much for your interest. We really
appreciate it, and congratulations to [audio break].

One question from the phone.

OPERATOR: Thank you. Angela Stewart, with the Star Ledger Newspaper, your
line is now open.

QUESTIONER: I just wanted to confirm this. In the U.S. last year, there
were nine cases of rubella; is that accurate?